I am having trouble with my nose/sinuses and skin on my face. Whenever I go outside in cooler air and then come back inside to a warmer environment (I don’t have to be outside long- maybe 1-2 minutes), the inside of my nose starts to burn and it get stuffy. The outside of my nose also turns red. After a while, I develop a tingling sensation in my cheeks and my nose will continue to burn. The tingling sensation seems to be around the sinus area. My nose also will feel very dry inside and cheeks will also flush and get warm. I also break out in blotches on my face and my chest will flush and tingle. My rhinitis.

I suffer from moderate-severe seasonal allergies and get weekly allergy shots. I also have been diagnosed with dermatographic urticaria so I assume that I have a lot of histamine in my body and my mast cells are acting up.

What is the cause of this—especially the burning inside my nose, face tingling and burning/warm cheeks? Could this be another form of urticaria? Sometimes my nose/face will turn red if I am warm in my bed as well. I do not itch or get welts on my skin, but it will burn and turn warm. My doctor does not believe that this is rosacea.

My primary physician said that rhinitis and sinusitis (nose and sinus allergies and inflammation) are known to cause tingling on nose and surrounding area due to the pressure on the nerves because of the inflammatory fluid. He did said that the flushing could be from my allergies.

Please help me to try and understand what is happening to my body. This is really starting to affect my life

1. Firstly, there are multiple medications that you are currently taking which all act on histamine receptors in your body and worsen dryness, tingling, burning and flushing with their anti-cholinergic effects. These are:a. Flexeril (Cyclobenzaprine)b. Mucinex (Guaifensin)c. Benadryl (Dipenhydramine)d. Sudafed (Pseudoephedrine)e Acycliovir (Acyclovir)You have not mentioned indications (why these were started, continued and by whom) and the dosage of each. I recommend that you discuss this with your physician/s and reduce your medication and their side effects. Short term steroids should not be a problem.

2. Treatment of vasomotor or intrinsic rhinitis will require a combination of an anti-histaminic (such as levocetrizine, rupatidine or fexofenadine) and an anti-leukotriene such as montelukast or zileuton), along with a steroid nasal spray, steam inhalation and saline nasal washes.

3. Your dermatographic urticaria seems to be triggered by non-specific allergy to change in temperature. You should have a trial with sodium cromoglycate, especialy if examination of blood and nasal secretions shows excessive eosinophils and mast cells. Flushing or redness of the nose results from local allergy which causes causes local capillaries and blood vessels to dilate and leak. The cause of dermatographism remains unknown. Do you have any dental caries, gum inflammation or gastrointestinal problems?

4. There is no cure for allergy, however by avoiding antigenic challenge, you may reduce the reaction. This is difficult in non-specific allergy such as changes in light, temperature., however you may reduce the rate of change in air temperature by covering your nose and face for some time to avoid sudden changes in temperature. You must search for exposure to specific antigens such as dust, dust mites, pollen in your house. Do you have any pets at home?

5. Do you have detailed clinical examination notes? For example, in vasomotor rhinitis, the nasal mucosa (inside lining) is very congested and red. There may be a DNS (Deviated Nasal Septum) or hypertrophied turbinates. Do you have sneezing, nasal discharge (rhinorrhea) or nasal stuffiness (obstruction)? Has your sinusitis been confirmed by a plain CT PNS (Para Nasal Sinuses) Scan?

Hope I have answered your query. If you have any follow up queries I will be available to answer them.

Thank you so much for your response to my questions- your answers are helpful. I had no idea that the medications that I take act on histamine receptors in my body worsening flushing, burning and dryness.

I take flexeril nightly for my neck pain from fibromyalgia. I did not realize that it had an affect on histamine in my body. I take the other drugs all for my allergies but I guess that it is possible to be overkill. I will talk to my doctor regarding these medications and will ask him about your recommendations.

1. The burning in my nose and flushing is from the dryness of the environment and change of temperature? What is the cause of the tingling of my face and sinuses? Could you please explain how they affect flushing if they are supposed to be “anti-cholinergic?”

I do not have any dental caries or gum inflammation but I do suffer from GERD from time to time. I take zantac with my zyrtec everyday because I read that stopping the H2 histamine will help with the flushing. I do have 3 cats at home and one sleeps in my bedroom. My allergist says that I am allergic to cats but I am not sure if they bother me or not.

My dermatographic urticaria is new to me. I never had this trouble before. It seems even a slight scratch from my hairbrush on my face will cause a red XXXXXXX Is this usual?

2. Can dermatographic urticaria cause facial flushing and warm skin? Is it possible that I may be suffering from another type of urticaria which is causing my face to get warm and red and flush? This is what I am really concerned about. I don’t understand why I get flushed and I would like to understand more about it so when it occurs, I won’t get so anxious about it. If you could please try and explain this, I would feel much better. I can give you more information if necessary.

I do not have detailed clinical examination notes but recall my doctor telling me that my “nose was so swollen that the turbinates inside were almost touching.” That is why he prescribed the steroids. I also have a slight deviated septum on the left side of my nose. I do have some sneezing and am very stuffy and do have some nasal discharge.

3. Could you further explain the burning inside my nose when I change environments (go from cool to warm?)

4. Could you help me understand why I would flush randomly like lying in my bed—is this from histamine?

Thank you so much for your help. I really appreciate it. XXXXXXX

Answered by Dr. Sumit Bhatti 9 hours later

answer Id 25926; conversation id 25926

Dear XXXXXXX

Thank you for writing back,

1. Chronic cholinergic or stress induced urticaria may result from stress, sweating, changes in temperature and also explains your skin rash even when you are warm or in bed. Such rashes are typically smaller than hives or angioedema and are not considered XXXXXXX Stimulation of the parasympathetic nervous system leads to release of histamine leading to dryness, tingling, burning and flushing. It may help to see close up images of the skin rash if possible. It responds to anti-histaminics (which you are already taking like Zyrtec / cetrizine).

2. Anti-cholinergics may not always block and may even enhance this response because of the following reasons:a. There are different types of anti-cholinergic receptors. Each drug has a different modes of action.b. Parasympathetic suppression leads to relative over-activity of the sympathetic nervous system.c. After a severe episode there may be temporary depletion of histamine leading to a symptom free period in spite of exposure to triggers.

3. After an allergic response as started, histamine is only one of the cocktail of substances released when mast cells burst. These include cytokines, interleukins, leukotrienes, and prostaglandins, tumour necrosis factors, SRS-A (Slow reacting Substance of Anaphylaxis) into the surrounding tissue causing dilation and leakage of blood vessels leading to flushing, mucous secretion, nerve stimulation (tingling), and smooth muscle contraction. This results in rhinorrhea, itchiness then dryness, burning and many other responses. In chronic allergy, cell mediated immunity is also involved.

4. All these factors make it extremely difficult to explain all the effects, which may seem paradoxical to you at times. Once allergy has developed, only blocking histamine will not counteract all these inflammatory mediators. The only other drugs that we have at this point in time are anti-leukotrines and steroids. This explains why we cannot control all the effects of allergy after it develops. This is where avoidance of triggers, steroid nasal sprays and sodium cromoglycate (mast cell stabilizer) are helpful.

5. You will have to take a trial by isolating your pets for some time.

Hope I have answered your query. If you have any follow up queries I will be available to answer them.

Thank for your detailed responses to my questions, you are really very helpful. I have been to a lot of doctors and no one has ever explained anything as well as you have.

This afternoon I was running some errands and at one point (after going in from outside- the temperature outside was around 60 degrees), parts of my face flushed and got very warm to the touch. My face also became very dry and burning. It is 11 pm now and my face is no longer red but feels very tight and dry (almost feels like I got a face lift). When this initially occurred this afternoon, I was very nervous before it happened. Ever since earlier, I have been a nervous wreck.

I want to add that this also occurred after drinking coffee which I usually do not have. My lips are also incredibly dry and my skin feels very tight.

You are right in that all of these symptoms are quite paradoxial. I am so confused. Does this sound related to my allergies as well?

Thank you again, XXXXXXX

Answered by Dr. Sumit Bhatti 3 hours later

answer Id 26064; conversation id 26064

Dear XXXXXXX

Thank you for following up.

1. The tightness and stiffness that you feel under the skin is due to tissue edema as a result of your allergy. Our skin is the largest organ in our body and such localized reactions are not XXXXXXX

2. You need to discuss all the above with your physician/s and treat this condition along the guidelines that I have mentioned above.

3. I must again emphasize that it is not possible to cure allergy, especially non-specific allergy. However by readjusting your medication and avoidance of triggers, it should be possible for you to control it.

Thank you for your response. I plan to discuss this all with my doctor at my appointment this week. I assume that the burning sensations on my face are as a result of the edema as well? Can the skin feel very warm as well? Can allergic reactions be worse if a person is stressed out or anxious?

You also mentioned that chronic cholinergic or stress induced urticaria can cause rashes smaller than hives. This would be the flushing that I get on my face and chest, correct?

I am glad thay you do not think that my symptoms sound like rosacea as I experienced the burning and redness today and became very scared. I will try not to worry so much as my anxiety often gets the best of me at times.

I believe that these are the last of my questions and will present your recommendations to my doctor.

Thank you so much for your help! XXXXXXX

Answered by Dr. Sumit Bhatti 3 hours later

answer Id 26093; conversation id 26093

Dear XXXXXXX

I just wanted to add a few points:

1. The burning sensations are a result of edema and inflammatory mediators / chemicals released locally into the affected area. Skin warmth is due to increased blood flow or reduced sweating. Stress worsens the immune response.

2. The flushing is part of the rash which usually does not progress to wheals.